Sacroiliac Joint Correction - A Different Model

By Marc Heller, DC

So many of our patients have chronic sacroiliac dysfunction. I have written several times about this problem, from several perspectives. This article will describe the work of Richard DonTigny, a physical therapist from Havre, Mont.

DonTigny has developed a home program, a set of basic exercises to reset the patient's sacroiliac (SI) joint, as well as a simplified form of mobilization for the SI joint. DonTigny's work all goes in one direction, taking the anteriorly [forward] rotated ilium in a posterior [backward] direction. DonTigny does this bilaterally on every SI patient. When I was introduced to this work, I was quite skeptical; it seemed too simple. I am still not sure if DonTigny's biomechanics are correct. He tends to see nearly all lower back pain as a result of this pattern of SI dysfunction, while I tend to look more broadly. What I do know is that his procedures (both those the practitioner does and those the patients do for themselves) are very helpful for selected patients.

Many of our low back pain patients return to the office with a recurrence of posterior or anterior innominate [hip] pattern: iliums [the uppermost and largest region of the coxal bone] rotated in the sagittal [left/right] plane. Especially when this malalignment is associated with sacroiliac joint tenderness and other indicators of sacroiliac dysfunction, it tells us the joint is not functioning properly.

DonTigny's basic indicator is tenderness. He checks the medial aspect of the upper PSIS [posterior superior iliac spine - the upper backside ridge of the hip bone], the medial aspect of the ilium at the S3 level, and the PIIS [posterior inferior iliac spine - bony protrusion below the PSIS]. When one or more of these are tender, he feels the SI is involved. He also notes leg length, and tests whether his procedures shorten the leg after correction.

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[To help stabilize this joint, there are several things both patient and practitioner can do: One basic tool is enhancing abdominal tone, particularly of the transverse abs, pelvic floor, and multifidi (which run vertically alongside the spine). Another is the application of massage techniques such as the cross-frictional massage or the Graston Technique which break up adhesions and initiate first-stage healing in the ligaments and tendons surrounding the joint.] [But] what can patients do themselves? DonTigny has developed a series of simple exercises that reset the joint. If the unstable patient will correct their own SI alignment daily, or (better yet) several times a day, they will tend to "hold the adjustment" much better.

Sacroiliac Self-Correction Exercises

What are the basic exercises that reset the SI? The first one will look familiar to those of you familiar with post-isometric relaxation or muscle energy technique. I have reproduced a whole series of pictures, showing different positions in which to do the same basic exercise. The basic routine is to have the patient bring the leg up to the chest, grasp the leg with both arms, and push outward with the leg against resistance. DonTigny recommends pushing outward hard for five to 10 seconds, then alternating legs, doing each side three to five times. Note that this can be done supine, sitting, standing using a chair, or in a doorway.

The second type of exercise is performed supine, with one knee bent, pushing the knee directly along the line of the femur. As you do this, the pelvis will lift on that side, slightly off the surface. You can get a little better motion into the pelvis by wrapping a long belt or strap around the knee, and pushing the knee into the strap (not pictured). Note the sagittal plane torque this is trying to produce in the pelvis. Do this three times on each side, holding for five to 10 seconds at the top. I find that on the involved side, it will feel much stiffer, and it is harder to lift the pelvis freely.

The third set of exercises involves flexing the hip as far as you can, simultaneously pulling it out to the side of the body. A second variation of this is done using a chair or bench and bending forward on the bent- leg side. I would have patients who have possible disc issues, especially those sensitive to flexion, be careful with these by keeping the spine in neutral, or avoiding these exercises altogether.

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I recognize this is a different model of the SI than most of us use. I recommend you read DonTingny's articles for a deeper understanding of his view of the biomechanics and pathomechanics of the SI joint.

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Keep an open mind - this is probably nothing like what you usually do to correct the SI joint. I have found these procedures quite effective for selected patients. These techniques seem to work best for the patient with an anterior rotated ilium, found usually on the right, when the right SI also is fixated.